IT IS ALWAYS THE QUIET ONES

One warm summer night here in Norway, we responded to a fire on a day-cruiser anchored just 20 metres from shore. The five people on board had a wild party going on, when a petrol stove tipped over and the boat lit up. Everone jumped into the water and swam to shore, except one woman in her fifties. She was observed next to the burning boat, quietly treading water, without any obvious signs of distress. Then, after about half a minute, she quietly slipped under the surface and was gone.

On our arrival about 10 minutes later, one of the paramedics immediately went in. Incredibly, he was able to locate her and drag her to shore. After 30 minutes of CPR we had to make the call. She was dead. Of course, she could have suffered some terminal arrhythmia that didn’t show on autopsy, but more likely she was a victim of her friends not knowing what a real drowning looks like.

Dr Francesco A PiaDr Francesco A Pia is an interesting person and a legend. He worked as a lifeguard for 21 years. Early in his career, back in 1968, he started filming his colleagues rescuing drowning people.

(Actually, nowhere in my sources does it explicitly say his friends were doing any rescuing while he was filming, comfortable in his beach chair , but I have to assume that’s how it went down.)

Anyway, in his videos he observed how most of the victims displayed the same terminal behaviour before drowning. This was the original research that led him to describe the Instinctive Drowning Response.

His most important finding was how drowning is a quiet affair, without the violent panicky splashing and desperate calling for help we normally imagine. Of course, a swimmer calling for help is in distress, but it’s the quiet ones who are really in trouble.

The instinctive drowning response is a highly autonomous state, where the victim is using all his energy and oxygen just to keep his mouth above water. They don’t have enough air to call for help. They don’t have enough energy to swim anywhere or wave for help. All they have is about 20-60 seconds before they go under.

This partly explains the many studies demonstrating how many drownings occur in guarded pools or environments, where other capable swimmers are about. Experienced lifeguards and surf rescue swimmers know this and look out for the quiet ones too.

The Instinctive Drowning Response
This is how Frank Pia describes the Instinctive drowning response in an old issue of On Scene which is a US coast guard publication. I know how you all collect old issues of On Scene but just in case there is a gap in your collection, it’s here on page 14.

1. Except in rare circumstances, drowning people are physi- ologically unable to call out for help. The respiratory system was designed for breathing. Speech is the secondary, or overlaid, function. Breathing must be fulfilled, before speech occurs.

2. Drowning people’s mouths alternately sink below and reappear above the surface of the water. The mouths of drowning people are not above the surface of the water long enough for them to exhale, inhale, and call out for help. When the drowning people’s mouths are above the surface, they exhale and inhale quickly as their mouths start to sink below the surface of the water.

3. Drowning people cannot wave for help. Nature instinctively forces them to extend their arms laterally and press down on the water’s surface. Pressing down on the surface of the water, permits drowning people to leverage their bodies so they can lift their mouths out of the water to breathe.

4. Throughout the Instinctive Drowning Response, drowning people cannot voluntarily control their arm movements. Physiologically, drowning people who are struggling on the surface of the water cannot stop drowning and perform voluntary movements such as waving for help, moving toward a rescuer, or reaching out for a piece of rescue equipment.

5. From beginning to end of the Instinctive Drowning Response people’s bodies remain upright in the water, with no evidence of a supporting kick. Unless rescued by a trained lifeguard, these drowning people can only struggle on the surface of the water from 20 to 60 seconds before submersion occurs.

What to look for
Mario Vittone, of the US coast guard and a leading expert on drowning, puts it another way on his excellent blog on water safety. Here is his description of the drowning person:

Head low in the water, mouth at water level

Head tilted back with mouth open

Eyes glassy and empty, unable to focus

Eyes closed

Hair over forehead or eyes

Not using legs

Hyperventilating or gasping

Trying to swim in a particular direction but not making headway

Trying to roll over on the back

Appear to be climbing an invisible ladder.

Drowning footage
Here’s one of the people drowning captured by by Dr. Pia, showing the typical behaviour. And also being ignored by people in the immediate vicinity.

Here’s another video from Bondi Beach in Sydney, showing a person drowning. At the beginning, he’s thrashing a bit, but then gets more quiet. Lots of other people are playing in the water, seemingly unaware of the person in serious distress just a few meters away from them:

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About ScanCrit

A blog on anaesthesia, intensive care and emergency medicine. In-hospital and outside. Mostly focusing on the critically ill patient. Written by two Scandinavian senior anaesthetic registrars turned consultants.

This is our way of keeping log of articles and interesting things we come across in our work and on the internet. Should any of you out there stumble across this blog and find it useful then all the better.

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